Failure to Follow Physician Orders for Pressure Ulcer Prevention and Skin Checks
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents, specifically in the areas of pressure ulcer prevention and skin integrity monitoring. For one resident with dementia and severe cognitive impairment, the air mattress was consistently set at 400 pounds, which was not in accordance with the physician's order specifying a comfort setting between 100 and 120 pounds. Additionally, weekly skin checks were not completed as ordered, and there was no documentation of refusal or explanation for the missed assessments. Interviews with nursing staff and the Director of Nursing revealed a lack of awareness regarding the incorrect mattress setting and missed skin checks. Another resident, assessed as high risk for pressure ulcers due to diagnoses including dysphagia, Huntington's Disease, and severe malnutrition, also did not receive weekly skin checks as ordered by the physician. The medical record showed only sporadic documentation of skin checks, with no evidence of resident refusal for the missed assessments. Despite staff signing off on the treatment administration record, the actual skin checks were not performed as required, and this discrepancy was not identified by nursing leadership until brought to their attention during the survey. A third resident, admitted with muscle wasting and heart disease and requiring moderate assistance with activities of daily living, had a physician's order for weekly skin checks that were not completed. The last documented skin check occurred prior to the resident's admission, and subsequent assessments were either incomplete or missing. The resident reported that no one had checked their skin since admission, and there was no documentation of refusal. Nursing staff and the DON confirmed that weekly skin checks should be performed and documented, but were unaware of the missed assessments until the survey.